Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that residents' weights were properly monitored and that significant weight changes were promptly addressed for three out of fifteen residents reviewed. According to the facility's policy, any weight change greater or less than 5 pounds within 30 days should be retaken for confirmation, and the dietitian is responsible for reviewing monthly weights and addressing negative trends. For one resident with diagnoses including depression and severe protein-calorie malnutrition, a 7.3% weight loss was recorded over a month, but there was no evidence that this significant weight loss was identified or that any intervention was implemented. Similarly, another resident experienced a rapid weight drop, but a timely re-weight was not obtained, resulting in an inaccurate MDS assessment. A third resident, also with severe protein-calorie malnutrition, lost 8.39% of body weight in a month, with no documentation of the weight loss being identified or addressed. Staff interviews confirmed that re-weights should have been obtained sooner and that the facility did not follow its own policy for monitoring and responding to significant weight changes. The lack of timely identification and intervention for significant weight loss in these residents, some of whom had critical conditions such as severe protein-calorie malnutrition, represents a failure to provide adequate food and fluids to maintain residents' health as required by facility policy and regulatory standards.